Beware of the government’s NHS personal healthcare budgets

The government wants personal health budgets introduced for NHS patients across the country. In this post, Richard Blogger looks at the problems personal healthcare budgets could create.

Who could argue against healthcare personalised to our needs? Personalisation of NHS services implies that you have choice and are included in the decision making about your NHS care, while still having the reassurance of free at the point of use and not being subject to US-style denial of care if you do not have the funds.

However, the government is using the guise of “personalisation” to give us a policy where the spectre of US-style care appears closer than it has ever been.

The coalition government claims that the only way that we can get personalisation of care is if we pay for it ourselves using a Personal Healthcare Budget.

What does this mean?

Under the government's plan, people who use the NHS frequently - patients with long term conditions or who receiving NHS Continuing Care - will have their needs assessed. Based on this assessment, they will be allocated a budget. The patient will then be expected to find the providers for the care that they need and contract these providers to deliver the care. NHS managers do this all the time - it is called procurement. NHS patients will be expected to do the work of professional procurement managers.

Personal Healthcare Budgets (PHBs) were not discussed at the 2010 election and are little discussed now, but they will soon be implemented across the entire NHS. In its direct payments for healthcare document, the Department of Health says that the government will legislate this summer to allow people to have a separate bank account to hold a PHB and change the law to allow patients to pay for NHS services.

The document says that a PHB “would not normally pay for hospital care, medication or GP services” it does not outright exclude these. The plan is that patients with long term conditions or disabilities will be “offered” a PHB.

They make it sound that PHBs will be optional, but the Department of Health does not say how CCGs trying to cut administration costs will be able to manage having two separate groups of patients, some paying for their care and some not.

To support its policy, the Department of Health has conducted pilots across the country. Some of these pilots were not popular - for example, in Havering in 2010, the Primary Care Trust failed to recruit any patients into the pilot. The final pilot only managed to recruit 1000 patients across England, varying from people with NHS Continuing Healthcare (very ill people typically receiving care outside of acute hospitals), to people with long term conditions like diabetes, multiple sclerosis, mental health and COPD.

The wide scope of the pilot shows that the government intends PHBs to be widespread, with almost no service untouched.

The government says that the PHB pilot produced “positive evidence”, but even a cursory glance of the actual report shows that the results were mixed at best. The pilot says that PHBs did not improve health status nor improve mortality, so there were no clinical improvements.

Furthermore, there were no savings either. The pilot was tiny – just 1000 people tried PHBs, when a million people use the NHS every 36 hours.

Implementing PHBs – assessing personal needs, allocating budgets and reassessing needs and budgets when circumstances change – will be a huge administrative upheaval. So this fundamental change will happen even though there is no proof of clinical improvements or financial savings.

The pilot did report improved psychological wellbeing of people on PHBs, particularly people with large budgets (continuing healthcare). The conclusion was that PHBs gave “greater choice and control”. However, in the Coalition’s NHS where finances are worse than at any time in the history of the service, you have to question why we have to have yet another administrative change that will neither save money nor improve clinical outcomes.

The core principle of the NHS is that care is free at the point of delivery and this means that patients should not have to pay for treatment. A direct payment for care, by a patient via a special PHB bank account, breaks this NHS principle.

Personalisation is about choice and being involved in that choice. We have that choice already. There is no need for patients to be involved in complex procurement. Householders who have had a kitchen fitted will recognise the effort it takes to employ the various contractors and ensure that they do their work at the right time, to the required quality and within a budget. Now imagine how difficult it is to procure your treatment from multiple clinicians when you are feeling ill.

A similar situation exists in social care, where Direct Payments have been available for several years. There are now private budget management companies who – for a fee – will procure the services a patient needs. This is effectively the privatisation of procurement, and since the service is carried out by a third party it is difficult to describe it as personal choice. Since the management companies take a fee, there is less money for the patient.

We do not need to purchase healthcare ourselves to get personalisation and PHBs are likely to make life more difficult for people at a challenging time of their lives. Yet again, this is a policy that was not mentioned at the 2010 election. If it had been, it is unlikely that the public would have voted for a political party promoting PHBs.